17-06-13 ELECTRICAL PARTS AND SUPPLIES



1841500000-206375166687517-06-13 ELECTRICAL PARTS AND SUPPLIESpART 3 OF 3Revised 07/24/2017Please include completed forms with your submitted proposals and USB flash drive Attachments: FORM A: Supplier Information FORM B: MWBE Instructions and Participation Report (see separate attachment)FORM C: Reference Survey InstructionsFORM D: Reference Survey FORM E: General CertificationsFORM F: Price Schedule – (See separate attachment & return an electronic copy on the USB drives)FORM G: EDGAR CertificationsFORM H: ExceptionsFORM I: Conflict of Interest Instructions and Questionnaire (Form CIQ)FORM J: Instructions for Completion of Disclosure of Interested Persons Certification (HB 1295)FORM K: IRS Form W‐9FORM L: Certificate of Insurance (Acord Form) or a letter from its insurance provider stating that Proposer can provide the levels of insurance required in this RFP.FORM M: Acknowledgement Form FORM N: Not UsedFORM O: Criminal History Background Check Form 0017-06-13 ELECTRICAL PARTS AND SUPPLIESpART 3 OF 3Revised 07/24/2017Please include completed forms with your submitted proposals and USB flash drive Attachments: FORM A: Supplier Information FORM B: MWBE Instructions and Participation Report (see separate attachment)FORM C: Reference Survey InstructionsFORM D: Reference Survey FORM E: General CertificationsFORM F: Price Schedule – (See separate attachment & return an electronic copy on the USB drives)FORM G: EDGAR CertificationsFORM H: ExceptionsFORM I: Conflict of Interest Instructions and Questionnaire (Form CIQ)FORM J: Instructions for Completion of Disclosure of Interested Persons Certification (HB 1295)FORM K: IRS Form W‐9FORM L: Certificate of Insurance (Acord Form) or a letter from its insurance provider stating that Proposer can provide the levels of insurance required in this RFP.FORM M: Acknowledgement Form FORM N: Not UsedFORM O: Criminal History Background Check Form FORM A: supplier information This Form A is required. See HISD Policy CHE (Local). legal name of supplier: ___________________________________________________________________data universal numbering system (duns) number: _____________________________________________type of business/description of products and/or services provided:_____________________________________________________________________________________________________________________________________________________________supplier mailing address: __________________________________________________________________city: _____________________________ state: ______________ zip code: ______________________supplier street address: __________________________________________________________________city: _____________________________ state: ______________ zip code: ______________________telephone: __________________________________ fax: ______________________________________contact person’s name: ___________________________________________________________________contact person’s telephone number: _______________________ fax: ___________________________contact person’s e-mail address: ___________________________________________________________type of business entity: ? publicly traded corporation ? private corporation ? limited partnership ? partnership ? sole proprietorship ? not for profit entitynumber of full time employees: _________________ number of part time employees: _______________is supplier is a resident bidder? ? yes ? noa resident bidder refers to a person whose principal place of business in the state of texas,Including a supplier whose ultimate parent company or majority owner has its principal place of business in this state.city and state of supplier's principal place of business: __________________________________________ if not texas, does the state have preferential treatment on bids? ? yes ? no if yes, what percentage: ____________%number of years supplier has been in continuous operation:______________________________________number of years supplier has been in business under its present business name: _____________________has supplier conducted business with the district under another name? ? yes ? noIf yes, provide other name(s):_______________________________________________________________________________________________________________________________________number of years doing business with hisd: __________________________________________________________________does supplier have a parent company or subsidiary that currently conducts or that has previously conducted business with the district? ? yes ? noIf yes, name of parent company and/or subsidiary: __________________________________________________________________________________________________________________________________________________do you have experience with other school districts? ? yes ? noif yes, names of school districts___________________________________________________________________ _______________________________________________________________________________________________does supplier have any owners, principal shareholders or stockholders, officers, agents, salespeople or key employees who have been members of the hisd board of education during the last 5 years? ? yes ? noIf yes, name(s) and title(s): ________________________________________________________________________does any officer, partner, owner, sales representative and/or spouse work for hisd? ? yes ? nodoes supplier have any owners, principal shareholders or stockholders, officers, agents, salespeople or key employees who are district employees or who are members of a district employee’s immediate family who either work or who may potentially work on this contract with the district? ? yes ? noIf yes, name(s) and title(s): ______________________________________________________________________________________________________________________________________________________________________names of authorized agents, including any person or entity authorized to ‘act with’ or ‘act on your behalf,’ such as consultants, sub-contractors, re-sellers, lobbyists, confidants, etc., whether compensated or not compensated: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________does supplier have relationship(s) with any political action committees? ? yes ? noif yes, name(s) of of pac(s)_______________________________________________________________________has supplier (including any owner, principal shareholder or stockholder, officer, agent, salesperson, or employee) been involved in past, pending, or present litigation involving the District? ? yes ? noif yes, please provide the style and status of the case as well as the type of litigation: __________________________________________________________________________________________________________________financial and business references, including bank with which supplier conducts business:name of bank with which supplier conducts business: ___________________________________________________bank officer: _____________________________ officer’s phone number: _______________________________name of other banking/financial institution(s): _______________________________________________________ _______________________________________________________ name of insurance companies:insurance companiesinsurance companieshisd encourages the participation of minority and women owned busineses. Is supplier a minority and/or woman owned company? ? yes ? noif yes, what percentage of ownership is minority or woman owned _____________%check one of the following: ? supplier will provide goods and services with own work force ? supplier will purchase goods directly from the manufacturer or other supplierhisd can only do business with equal opportunity employers.do you advertise as an equal opportunity employer? ? yes ? nodo you have a written non-discriminatory policy of employment? ? yes ? nohas this policy been circulated throughout your organization? ? yes ? noperson to contact regarding equal opportunity information issues:name: _______________________________________ title: ____________________________________-----QUESTIONS REGARDING PROCUREMENT E-COMMERCE SOLUTIONS---- more information regarding the following questions and hisd’s e-procurement system may be found on part II, section 2.7 of this solicitation. (If section 2.7 in part ii is not applicable to this rfp, REMOVE QUESTIONS 22 TO 28)name of contact person regarding it issues in your company: __________________________________________________is supplier participating in the optional e-commerce method described in part II, section 2.7 of this rfp? ? yes ? nocan supplier provide hisd with periodic preformatted flat file updates of your catalog? ? yes ? nodoes supplier have e-commerce capability? ? yes ? nodoes supplier have punch-out catalogs in place today? ? yes ? nodoes supplier have any internal electronic catalogs with any customers? ? yes ? nois supplier capable of providing a dedicated website with your catalog with hisd’s pricing? ? yes ? noif yes, can your website interface with sap public section 7.0 / ecc 6.0 open catalog interface (oci) compliant? ? yes ? noi attest that i have answered the questions regarding supplier information truthfully and to the best of my knowledge.______________________________________________officer’s signature______________________________________________printed name______________________________________________titleFORM b: MWBE INSTRUCTIONSINSERT MWBE INSTRUCTIONSPlease refer to Attachment B-MWBE Participation Report that is located on HISD’s Procurement Web Site.FORM C: REFERENCE SURVEY INSTRUCTIONSProposer must complete and return Form C as part of this RFP.The Evaluation Committee considers Proposer’s reputation and reputation of Proposer’s goods or services in its evaluation of this Proposal. Proposer to complete FORM CThe District requests the proposer to send FORM D (Proposer Reference) to their respected Clients for the purpose of their Client to complete.The proposer’s Client is then to send the completed FORM D to Kevin.March@ (Sourcing Specialist), no later than the proposal due date of October 24, 2017 at 2:00pm CSTPlease provide the name and contact information of all references to whom Proposer intends to send the FORM D (References). Please provide the name and contact information of all references to whom Proposer intends to send the Survey. (1) ________________________________________ ________________________________________ Name of Entity or Business Contact Name ________________________________________ ________________________________________ Email Address Mailing Address ________________________________________________________________________________ Phone NumberGoods and/or services provided(2) ________________________________________ ________________________________________ Name of Entity or Business Contact Name ________________________________________ ________________________________________ Email Address Mailing Address ________________________________________________________________________________ Phone NumberGoods and/or services provided(3) ________________________________________ ________________________________________ Name of Entity or Business Contact Name ________________________________________ ________________________________________ Email Address Mailing Address ________________________________________________________________________________ Phone NumberGoods and/or services providedFORM D: REFERENCE SURVEY0485775This requested reference is for HISD RFP #17-06-13 – Electrical Parts and SuppliesProposer’s Company Name_________________________________________________________________0This requested reference is for HISD RFP #17-06-13 – Electrical Parts and SuppliesProposer’s Company Name_________________________________________________________________To Whom It May Concern:HISD is requesting the company completing this reference request, to send directly to HISD via email to Kevin.March@ on or before October 24, 2017at 2:00pm CST.NO.CRITERIAUNITSCORE1Ability to Manage Cost(1-10)2Quality of Product(s) and/or Services(1-10)3Quality of Customer Service(1-10)4Quick Response Time(1-10)5Ability to Maintain Confidentiality(1-10)6Close Out Process (invoicing, no unexpected fees)(1-10)7Communication(1-10)8Ability to Follow Rules, Regulations, and Requirements(1-10)9Overall Customer Satisfaction Based on Performance (comfort level using company again)(1-10)10Safety(1-10)TOTAL POINTS (out of 100): ____________How long have you done business with the Supplier? _______________________________________________________-47625218440The Houston Independent School District (HISD) has implemented a process to collect Vendor performance evaluations. HISD may use the information provided in its assessment of the above Vendor in order to determine a responsive and responsible procurement. The Vendor listed above has chosen to participate in this process and listed you as a past or present client for whom it has provided goods and/or services______________________________________ ___________________________________________________Company Name Providing Reference SignatureDate0The Houston Independent School District (HISD) has implemented a process to collect Vendor performance evaluations. HISD may use the information provided in its assessment of the above Vendor in order to determine a responsive and responsible procurement. The Vendor listed above has chosen to participate in this process and listed you as a past or present client for whom it has provided goods and/or services______________________________________ ___________________________________________________Company Name Providing Reference SignatureDateFORM E: General CERTIFICATION FORMSCERTIFICATION OF CODE OF SILENCEThe Board of Education (Board) has adopted a “Code of Silence” policy (Board Policy CAA (Local)) attached by URL link hereto and incorporated by reference.The “Code of Silence" prohibits any communication regarding any RFP, bid, or other competitive solicitation between:Any person who seeks an award from the District or its affiliated entities (including, but not limited to, the HISD Foundation and the HISD Public Facility Corporation), including a potential supplier or supplier's representative, andBoard members, the Superintendent of Schools, senior staff members, principals, department heads, directors, managers, or other District representatives who have influence in the evaluation or selection process.The “Code of Silence” time period shall begin when the RFP is issued and ends upon the execution of the Contract. During the “Code of Silence,” campaign contributions, gifts, donations, loans, and any other items of value are prohibited between these parties, including candidates who have filed for election to the Board.I hereby certify that I have reviewed Board Policy CAA (Local) pertaining to the “Code of Silence,” I and agree and understand that non-compliance with the “Code of Silence” policy may result in disqualification. ________ Initials of Authorized Representative of SupplierCERTIFICATION OF COMPLIANCE WITH TEXAS FAMILY CODE PROVISIONAs per Section 14.52 of the Texas Family Code, added by S.B. 84, Acts, 73rd Legislature, R.S. (1993), all bidders must complete and submit with the bid the following: I, the undersigned Supplier, do hereby acknowledge that NO sole proprietor, partner, majority shareholder of a corporation, or an owner of 10% or more of another business entity is 30 days or more delinquent in paying child support under a court order or a written repayment agreement. I understand that under this provision, a sole proprietorship, partnership, corporation or other entity in which a sole proprietor, partner, majority shareholder or a corporation, or an owner of 10% or more of another entity is 30 days or more delinquent in paying child support under a court order or a written repayment agreement is NOT eligible to bid or receive a state contract.________ Initials of Authorized Representative of SupplierCERTIFICATION OF AUTHORIZATION, PERMITS, AND BUSINESS CERTIFICATES REQUIREMENTFor the duration of the Contract, Supplier must have and maintain current licenses, permits, fees, business certificates and similar authorizations required by the City of Houston, Harris Country, and the State of Texas to conduct business and provide awarded goods and/or services to the District. Upon the request of the District, Supplier shall provide copies of all licenses, business certificates permits and fees as being paid and current that are required to do business by the city, county and State for the type of business Supplier provides, or seeks to provide, to the District. Supplier understands and agrees to abide by the Authorization, Permits, and Business Certificates Requirement above. Supplier certifies that it has all current licenses, certificates, similar authorizations required by the City of Houston, Harris County, and the State of Texas to conduct business and/or provide awarded goods and/or services to the District. ________ Initials of Authorized Representative of SupplierCERTIFICATION OF ANTITRUST CERTIFICATION STATEMENT –Texas Government Code Section 2155.005My initials below affirms under penalty of perjury of the laws of the State of Texas that:I am duly authorized to execute this Proposal/Contract on my own behalf or on behalf of the company, corporation, firm, partnership or individual (Supplier) listed below;In connection with this proposal, neither I nor any representative of Supplier have violated any provision of the Texas Free Enterprise and Antitrust Act, Tex. Bus & Comm. Code Chapter 15;In connection with this bid, neither I nor any representative of the Supplier have violated any federal antitrust law; andNeither I nor any representative of Supplier have directly or indirectly communicated any of the contents of this proposal to a competitor of Supplier or any other company, corporation, firm, partnership or individual engaged in the same line of business as Supplier.________ Initials of Authorized Representative of SupplierCERTIFICATION REGARDING HAZARD ANALYSIS AND CRITICAL CONTROL POINTS (HACCP)All products purchased by HISD must be manufactured in compliance with HACCP regulations. Supplier certifies that: all products on this proposal are processed and packaged in a HACCP compliant plant. Supplier agrees Supplier further understands that HISD requires processors to maintain records and monitoring logs pertaining to HACCP compliance, at a minimum, in the following Key Areas of HACCP compliance:Hazard AnalysisCritical Control Points established and limits setPlanned procedures in place to correct processes when deviation may occurDetailed and accurate record keepingVerification proceduresEquipment installation and maintenanceMaster cleaning and sanitation scheduleOrientation for all employeesOngoing training on food safety and HACCP proceduresSeparation of food and chemical productsRefrigerated dock receiving and loadingMaster cleaning and sanitation scheduleTime/Temperature monitoringPest ControlSupplier further understands and agrees that documentation and monitoring logs must be verified by an acceptable third party auditing firm or government agency and provided to HISD upon request. Supplier also understands and agrees that if a processor loses inspection/processing rights or has a recall involving product sold to HISD, Supplier must notify HISD within 24-48 hours.________ Initials of Authorized Representative of SupplierCERTIFICATION OF SUPPLIER (AND IF APPLICABLE, SUBCONTRACTOR) NATIONWIDE CRIMINAL BACKGROUND CHECKSPursuant to sections 22.085 and 22.0834 of the Texas Education Code Sections 22.085 and 22.0834 and HISD Policy CJA (Legal), Supplier hereby certifies that all of Supplier’s employees, subcontractors and volunteers (including those hired before January 1, 2008) who have, or will have, continuing duties related to the contracted services, and who have, or will have, direct contact with students, have passed a national criminal history background record information review as required by those sections and by HISD Policy CJA (Legal). Supplier understands that if an employee subcontractor, or volunteer has a Disqualifying Criminal History, the District may elect not to enter into this Contract or may elect to cancel the Contract.“Disqualifying Criminal History” means: (1) a conviction or other criminal history information designated by HISD; (2) a felony or misdemeanor offense that would prevent a person from being employed under Texas Education Code § 22.085(a), that is: if at the time of the offense, the victim was under 18 or was enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an offense on conviction for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal Procedure; or (c) an offense under federal law or the laws of another state that is equivalent to (a) or (b).Supplier further certifies that:Supplier will immediately remove an employee, subcontractor, or volunteer from contract duties and notify HISD in writing within 3 business days if:Supplier receives information that an employee, subcontractor, or volunteer has a reported criminal history, orHISD objects to the assignment of an employee, subcontractor, or volunteer on the basis of the individual(s) criminal history review information (CHRI).Upon request, Supplier will provide HISD with the name and any other requested information of an employee, subcontractor, or volunteer so that HISD may obtain the CHRI on the individual(s).________ Initials of Authorized Representative of SupplierCERTIFICATION OF FELONY CONVICTION NOTIFICATIONPursuant to section 44.034 of the Texas Education Code, a person or business entity entering into a contract and/or agreement with HISD must give advance notice to HISD if the person or an owner or operator of the business entity has been convicted of a felony. The disclosure should include a general description of the conduction resulting in the conviction of a felony. HISD may terminate a contract with a person of business entity if HISD determines that the person or the business entity failed to give notice as required by section 44.034 or misrepresented the conduct resulting in the conviction. In such a case, HISD will compensate the person or business entity for services performed before the termination of the contract.---THIS NOTICE IS NOT REQUIRED OF A PUBLICLY HELD-CORPORATION ---Please check the following as applicable:? Supplier is a publicly held corporation; therefore the above reporting requirement does not apply.? Supplier is not owned nor operated by anyone who has been convicted of a felony.? Supplier is operated or owned by the following individual(s) who has/have been convicted of a felony:Name of Individual(s): ___________________________________________________________________________Detail of conviction(s), attach additional pages if necessary: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Initials of Authorized Representative of SupplierCERTIFICATION OF INSURANCE REQUIREMENTI, the undersigned Supplier, do hereby certify that I shall maintain all insurance policies required by and in accordance with Section 5.27 of this RFP. I further understand and agree that I must make the certificates of insurance and insurance policies available to HISD upon request.________ Initials of Authorized Representative of SupplierCERTIFICATION OF NON-COLLUSION STATEMENTI, the undersigned Supplier, do hereby certify that:All statements of fact in such proposal are true.Such Proposal was not made in the interest of or on behalf of any undisclosed person, partnership, company, association, organization or corporation.Such Proposal is genuine and not collusive or sham.Supplier has not, directly or indirectly by agreement, communication or conference with anyone, attempted to induce action prejudicial to the interest of the District or of any other bidder or anyone else interested in the proposed procurement.Supplier did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said bidder or anyone else would submit a false or sham bid or proposal, or that anyone should refrain from bidding or withdraw his bid or proposal.Supplier did not, in any manner, directly or indirectly seek by agreement, communication or conference with anyone to raise or fix the bid or proposal price of said bidder or of anyone else, or to raise or fix any overhead, profit or cost element of his bid or proposal price, or that of anyone else.Supplier did not, directly or indirectly, submit his bid or proposal price or any breakdown thereof, or the contents thereof, or divulge information on data relative thereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof, or to any individual or group of individuals, except to the District, or to any person or persons who have a partnership or other financial interest with said Proposer in his business.Supplier did not provide, directly or indirectly to any officer or employee of the District any gratuity, entertainment, meals, or anything of value, whatsoever, which could be construed as intending to invoke any form of reciprocation or favorable treatment.No officer or principal of the undersigned Supplier is related to any officer or employee of the District by blood or marriage within the third degree or is employed, either full or part time, by the District either currently or within the last two (2) years.No officer or principal of the undersigned Supplier nor any subcontractor to be engaged by the principal has been convicted by a court of competent jurisdiction of any charge of fraud, bribery, collusion, conspiracy or any other act in violation of any state or federal anti-trust law in connection with the bidding, award of, or performance of any public work contract and/or agreement with any public entity.I have answered the questions regarding non-collusion truthfully and to the best of my knowledge.________ Initials of Authorized Representative of SupplierSUPPLIER AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES, REGULATIONS, AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT SUPPLIER CERTIFIES COMPLIANCE WITH ALL PROVISIONS, LAWS, ACTS, REGULATIONS, ETC. AS SPECIFICALLY NOTED ABOVE. Supplier’s Name: _______________________________________________________________________________________Address, City, State, and Zip Code: ________________________________________________________________________Phone Number: ____________________________________ Fax Number: ____________________________________ Printed Name and Title of Authorized Representative: __________________________________________________________Email Address: ________________________________________________________________________________________Signature of Authorized Representative: _____________________________________________________________________Date: ___________________________FORM F:Please refer to Separate Attachment F - Pricing Schedule and place in Tab 7 as well as return an electronic copy on the USB drivesFORM G: EDGAR CERTIFICATIONSThe following certifications and provisions are required and apply when HISD expends federal funds for any contract resulting from this procurement process. Accordingly, the parties agree that the following terms and conditions apply to the Contract between the District and [name of supplier] (“Supplier”) in all situations where Supplier has been paid or will be paid with federal funds:REQUIRED CONTRACT PROVISIONS FOR NON-FEDERAL ENTITY CONTRACTS UNDER FEDERAL AWARDS APPENDIX II TO 2 CFR PART 200(A) Contracts for more than the simplified acquisition threshold currently set at $150,000, which is the inflation adjusted amount determined by the Civilian Agency Acquisition Council and the Defense Acquisition Regulations Council (Councils) as authorized by 41 U.S.C. 1908, must address administrative, contractual, or legal remedies in instances where contractors violate or breach contract terms, and provide for such sanctions and penalties as appropriate.Pursuant to Federal Rule (A) above, when HISD expends federal funds, HISD reserves all rights and privileges under the applicable laws and regulations with respect to this procurement in the event of breach of contract by either party. Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(B) Termination for cause and for convenience by the grantee or subgrantee including the manner by which it will be effected and the basis for settlement. (All contracts in excess of $10,000)Pursuant to Federal Rule (B) above, when HISD expends federal funds, HISD reserves the right to immediately terminate any agreement in excess of $10,000 resulting from this procurement process in the event of a breach or default of the agreement by Supplier in the event Supplier fails to: (1) meet schedules, deadlines, and/or delivery dates within the time specified in the procurement solicitation, contract, and/or a purchase order; (2) make any payments owed; or (3) otherwise perform in accordance with the contract and/or the procurement solicitation. HISD also reserves the right to terminate the contract immediately, with written notice to Supplier, for convenience, if HISD believes, in its sole discretion that it is in the best interest of HISD to do so. Supplier will be compensated for work performed and accepted and goods accepted by HISD as of the termination date if the contract is terminated for convenience of HISD. Any award under this procurement process is not exclusive and HISD reserves the right to purchase goods and services from other Supplier s when it is in HISD’s best interest.Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(C) Equal Employment Opportunity. Except as otherwise provided under 41 CFR Part 60, all contracts that meet the definition of “federally assisted construction contract” in 41 CFR Part 60-1.3 must include the equal opportunity clause provided under 41 CFR 60-1.4(b), in accordance with Executive Order 11246, “Equal Employment Opportunity” (30 FR 12319, 12935, 3 CFR Part, 1964-1965 Comp., p. 339), as amended by Executive Order 11375, “Amending Executive Order 11246 Relating to Equal Employment Opportunity,” and implementing regulations at 41 CFR part 60, “Office of Federal Contract Compliance Programs, Equal Employment Opportunity, Department of Labor.”Pursuant to Federal Rule (C) above, when HISD expends federal funds on any federally assisted construction contract, the equal opportunity clause is incorporated by reference herein. Does Supplier agree to abide by the above? YES ________ Initials of Authorized Representative of Supplier(D) Davis-Bacon Act, as amended (40 U.S.C. 3141-3148). When required by Federal program legislation, all prime construction contracts in excess of $2,000 awarded by non-Federal entities must include a provision for compliance with the Davis-Bacon Act (40 U.S.C. 3141-3144, and 3146-3148) as supplemented by Department of Labor regulations (29 CFR Part 5, “Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction”). In accordance with the statute, contractors must be required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination made by the Secretary of Labor. In addition, contractors must be required to pay wages not less than once a week. The non-Federal entity must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a contract or subcontract must be conditioned upon the acceptance of the wage determination. The non-Federal entity must report all suspected or reported violations to the Federal awarding agency. The contracts must also include a provision for compliance with the Copeland “Anti-Kickback” Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFR Part 3, “Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States”). The Act provides that each contractor or subrecipient must be prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she is otherwise entitled. The non-Federal entity must report all suspected or reported violations to the Federal awarding agency.Pursuant to Federal Rule (D) above, when HISD expends federal funds during the term of an award for all contracts and subgrants for construction or repair, Supplier will be in compliance with all applicable Davis-Bacon Act provisions. Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(E) Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3708). Where applicable, all contracts awarded by the non-Federal entity in excess of $100,000 that involve the employment of mechanics or laborers must include a provision for compliance with 40 U.S.C. 3702 and 3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor must be required to compute the wages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided that the worker is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in excess of 40 hours in the work week. The requirements of 40 U.S.C. 3704 are applicable to construction work and provide that no laborer or mechanic must be required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or contracts for transportation or transmission of intelligence.Pursuant to Federal Rule (E) above, when HISD expends federal funds, Supplier certifies that Supplier will be in compliance with all applicable provisions of the Contract Work Hours and Safety Standards Act during the term of an award for all contracts by HISD resulting from this procurement process.Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(F) Rights to Inventions Made Under a Contract or Agreement. If the Federal award meets the definition of “funding agreement” under 37 CFR §401.2 (a) and the recipient or subrecipient wishes to enter into a contract with a small business firm or nonprofit organization regarding the substitution of parties, assignment or performance of experimental, developmental, or research work under that “funding agreement,” the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, “Rights to Inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative Agreements,” and any implementing regulations issued by the awarding agency.Pursuant to Federal Rule (F) above, when federal funds are expended by HISD, Supplier certifies that during the term of an award for all contracts by HISD resulting from this procurement process, Supplier agrees to comply with all applicable requirements as referenced in Federal Rule (F) above. Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(G) Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33 U.S.C. 1251-1387), as amended—Contracts and subgrants of amounts in excess of $150,000 must contain a provision that requires the non-Federal award to agree to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251- 1387). Violations must be reported to the Federal awarding agency and the Regional Office of the Environmental Protection Agency (EPA).Pursuant to Federal Rule (G) above, when federal funds are expended by HISD, Supplier certifies that during the term of an award for all contracts by HISD resulting from this procurement process, Supplier agrees to comply with all applicable requirements as referenced in Federal Rule (G) above. Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(H) Debarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2 CFR 180.220) must not be made to parties listed on the government wide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549.Pursuant to Federal Rule (H) above, when federal funds are expended by HISD, Supplier certifies that during the term of an award for all contracts by HISD resulting from this procurement process, Supplier certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation by any federal department or agency. Does Supplier agree? YES ________ Initials of Authorized Representative of Supplier(I) Byrd Anti-Lobbying Amendment (31 U.S.C. 1352)—Contractors that apply or bid for an award exceeding $100,000 must file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier must also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the non-Federal award.Pursuant to Federal Rule (I) above, when federal funds are expended by HISD, Supplier certifies that during the term and after the awarded term of an award for all contracts by HISD resulting from this procurement process, the Supplier certifies that it is in compliance with all applicable provisions of the Byrd Anti-Lobbying Amendment (31 U.S.C. 1352). The undersigned further certifies that:No Federal appropriated funds have been paid or will be paid for on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with the awarding of a Federal contract, the making of a Federal grant, the making of a Federal loan, the entering into a cooperative agreement, and the extension, continuation, renewal, amendment, or modification of a Federal contract, grant, loan, or cooperative agreement.If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of congress, or an employee of a Member of Congress in connection with this Federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions.The undersigned shall require that the language of this certification be included in the award documents for all covered sub-awards exceeding $100,000 in Federal funds at all appropriate tiers and that all subrecipients shall certify and disclose accordingly.Does Supplier agree? YES ________ Initials of Authorized Representative of SupplierRECORD RETENTION REQUIREMENTS FOR CONTRACTS INVOLVING FEDERAL FUNDSWhen federal funds are expended by HISD for any contract resulting from this procurement process, Supplier certifies that it will comply with the record retention requirements detailed in 2 CFR § 200.333. Supplier further certifies that it will retain all records as required by 2 CFR § 200.333 for a period of three years after grantees or subgrantees submit final expenditure reports or quarterly or annual financial reports, as applicable, and all other pending matters are closed.Does Supplier agree? YES ________ Initials of Authorized Representative of SupplierCERTIFICATION OF COMPLIANCE WITH THE ENERGY POLICY AND CONSERVATION ACTWhen HISD expends federal funds for any contract resulting from this procurement process, Supplier certifies that it will comply with the mandatory standards and policies relating to energy efficiency which are contained in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act (42 U.S.C. 6321 et seq.; 49 C.F.R. Part 18).Does Supplier agree? YES ________ Initials of Authorized Representative of SupplierCERTIFICATION OF EQUAL EMPLOYMENT STATEMENTIt is the policy of HISD not to discriminate on the basis of race, color, national origin, gender, limited English proficiency or handicapping conditions in its programs. Supplier agrees not to discriminate against any employee or applicant for employment to be employed in the performance of this Contract, with respect to hire, tenure, terms, conditions and privileges of employment, or a matter directly or indirectly related to employment, because of age (except where based on a bona fide occupational qualification), sex (except where based on a bona fide occupational qualification) or race, color, religion, national origin, or ancestry. Supplier further agrees that every subcontract entered into for the performance of this Contract shall contain a provision requiring non-discrimination in employment herein specified, binding upon each subcontractor. Breach of this covenant may be regarded as a material breach of the Contract.Does Supplier agree? YES ________ Initials of Authorized Representative of SupplierCERTIFICATION OF COMPLIANCE WITH BUY AMERICA PROVISIONSHISD has a preference for domestic end products for supplies acquired for use in the United States when spending federal funds (purchases that are made with non-federal funds or grants are excluded from the Buy America Act). Supplier certifies that it is in compliance with all applicable provisions of the Buy America Act. Does Supplier agree? YES ________ Initials of Authorized Representative of VendorCERTIFICATION OF ACCESS TO RECORDS – 2 C.F.R. § 200.336Supplier agrees that the District’s Inspector General or any of their duly authorized representatives shall have access to any books, documents, papers and records of Supplier that are directly pertinent to Supplier’s discharge of its obligations under the Contract for the purpose of making audits, examinations, excerpts, and transcriptions. The right also includes timely and reasonable access to Supplier’s personnel for the purpose of interview and discussion relating to such documents.Does Supplier agree? YES ________ Initials of Authorized Representative of SupplierCERTIFICATION OF APPLICABILITY TO SUBCONTRACTRSSupplier agrees that all contracts it awards pursuant to the Contract shall be bound by the foregoing terms and conditions.Does Supplier agree? YES ________ Initials of Authorized Representative of SupplierSUPPLIER AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES, REGULATIONS, AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT SUPPLIER CERTIFIES COMPLIANCE WITH ALL PROVISIONS, LAWS, ACTS, REGULATIONS, ETC. AS SPECIFICALLY NOTED ABOVE. Supplier’s Name: _______________________________________________________________________________________Address, City, State, and Zip Code: ________________________________________________________________________Phone Number: ____________________________________ Fax Number: ____________________________________ Printed Name and Title of Authorized Representative: __________________________________________________________Email Address: ________________________________________________________________________________________Signature of Authorized Representative: _____________________________________________________________________Date: ___________________________FORM H: EXCEPTION FORMAll deviations and exceptions to the RFP must be expressly stated in this Exception Form (additional pages to this form may be added if necessary). In the absence of any entry on this Exception Form, Supplier assures HISD of its full agreement and compliance with all specifications, terms and conditions, requirements and obligations of the RFP. All exceptions must detail the section number, paragraph number, page number, and the specific language excepted.YOU MUST SIGN AND SUBMIT THIS FORM WITH YOUR PROPOSAL REGARDLESS OF WHETHER THERE ARE EXCEPTIONS LISTED OR NOT.Supplier NameOfficer’s Signature Printed Name DateFORM I: CONFLICT OF INTEREST CERTIFICATION AND CONFLICT OF INTEREST QUESTIONNAIRE (CIQ) INSTRUCTIONSCONFLICT OF INTEREST CERTIFICATIONThe Board of Education (Board) has adopted a “Conflict of Interest Disclosures” policy (Board Policy BBFA (Local)) attached by URL link hereto and incorporated by reference.HISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local Government Officers as well as the conflict of interest standards set forth in EDGAR, 2 C.F.R. §?200.318 when HISD expends federal funds. No employee, officer, or agent may participate in the selection, award, or administration of a contract if he or she has a real or apparent conflict of interest. HISD local government officers must disclose conflicts of interest by completing Form CIS, Local Government Officer Conflicts Disclosure Statement. I hereby certify that I have read Board Policy BBFA (Local) pertaining to “Conflict of Interest Disclosures,” and I agree and understand that the failure of a Board member to disclose a conflict of interest may result in the debarment of a Supplier for 24 months.________ Initials of Authorized Representative of SupplierCONFLICT OF INTEREST QUESTIONNAIRE (CIQ) INSTRUCTIONSHISD is required to comply with Texas Local Government Code Chapter 176, Disclosure of Certain Relationships with Local Government Officers. H.B. 23 significantly changed the laws relating to Conflict of Interest Disclosures as well as the corresponding forms and required disclosures. As of September 1, 2015, Supplier must sign and complete the new Conflict of Interest Questionnaire (CIQ) and submit the CIQ with its proposal.In accordance with Chapter 176 of the Texas Local Government Code, any Supplier who does business with HISD or who seeks to do business with HISD must fill out the new Conflict of Interest Questionnaire (CIQ) whether or not a conflict of interest exists. A conflict of interest exists in the following situations:If the Supplier has an employment or other business relationship with a local government officer of HISD or a family member of the officer, as described by section 176.003(a)(2)(A) of the Texas Local Government Code; orIf the Supplier given a local government officer of HISD, or a family member of the officer, one or more gifts with the aggregate value of $100, excluding any gift accepted by the officer or a family member of the officer if the gift is: (a) a political contribution as defined by Title 15 of the Election Code; or (b) a gift of food accepted as a guest; orIf the Supplier a family relationship with a local government officer of HISD. “Supplier” means a person who enters or seeks to enter into a contract with a local governmental entity. The term includes an agent of a Supplier. The term includes an officer or employee of a state agency when that individual is acting in a private capacity to enter into a contract. The term does not include a state agency except for Texas Correctional Industries. Texas Local Government Code 176.001(7).“Business relationship” means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A)??a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B)??a transaction conducted at a price and subject to terms available to the public; or (C)??a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Texas Local Government Code 176.001(3).“Local government officer” means: (A) a member of the governing body of a local governmental entity; (B)??a director, superintendent, administrator, president, or other person designated as the executive officer of a local governmental entity; or (C)??an agent of a local governmental entity who exercises discretion in the planning, recommending, selecting, or contracting of a Supplier. Texas Local Government Code 176.001(4).“Family relationship” means a relationship between a person and another person within the third degree by consanguinity or the second degree by affinity, as those terms are defined by Subchapter B, Chapter 573, Government Code. Texas Local Government Code 176.001(2-a).SUPPLIER MUST SIGN AND SUBMIT FORM CIQ EVEN IF NO CONFLICT EXISTS.If no conflict exists, Supplier must fill out Box 1 and write N/A in Box 3.I hereby certify that I have read Form I, Conflict of Interest Questionnaire (CIQ) Instructions, and I agree and understand that the failure to disclose a conflict of interest and/or the failure to sign and submit Form CIQ, even if no conflict exists, with this proposal may result in disqualification.Name of Authorized Representative: ________________________________________________________________________Signature of Authorized Representative: _____________________________________________________________________Date: ___________________________FORM J: HISD CERTIFICATE OF INTERESTED PARTIES – FORM 1295Certificate of Interested Parties (Form 1295 – must be filled out electronically with the Texas Ethics Commission’s online filing application, printed out, signed, notarized, and attached to Supplier’s response to this solicitation.Houston ISD (“HISD”) is required to comply with House Bill 1295, which amended the Texas Government Code by adding Section 2252.908, Disclosure of Interested Parties. Section 2252.908 prohibits HISD from entering into a contract resulting from this RFP with a business entity unless the business entity submits a Disclosure of Interested Parties (Form 1295) to HISD at the time business entity submits the signed contract. The Texas Ethics Commission has adopted rules requiring the business entity to file Form 1295 electronically with the Texas Ethics Commission. “Interested Party” means a person: who has a controlling interest in a business entity with whom HISD contracts; orwho actively participates in facilitating the contract or negotiating the terms of the contract, including a broker, intermediary, adviser, or attorney for the business entity. “Business Entity” means an entity recognized by law through which business is conducted, including a sole proprietorship, partnership, or corporation.As a “business entity,” all Supplier s must electronically complete, print, sign, notarize, and submit Form 1295 with their proposals even if no interested parties exist. Proposers must file Form 1295 electronically with the Texas Ethics Commission using the online filing application, which can be found at . Proposers must use the filing application on the Texas Ethics Commission’s website to enter the required information on Form 1295. Proposers must print a copy of the completed form, which will include a certification of filing containing a unique certification number. The Form 1295 must be signed by an authorized agent of the business entity, and the form must be notarized. The completed Form 1295 with the certification of filing must be filed with HISD by attaching the completed form to the Supplier’s solicitation response.HISD must acknowledge the receipt of the filed Form 1295 by notifying the Texas Ethics Commission of the receipt of the filed Form 1295 no later than the 30th day after the date the contract binds all parties to the contract. After HISD acknowledges the Form 1295, the Texas Ethics Commission will post the completed Form 1295 to its website with seven business days after receiving notice from HISD. The acknowledgement of your 1295 form does not guarantee that you will be selected as an approved Supplier. An evaluation committee will select the Supplier (s) for the project and the Board of Education will approve it during the next available board meeting. An award or regret letter will be sent once the selection and approval process is complete. In the event that your proposal is not selected, we will request you to withdraw your 1295 form from the Texas Ethics Commission website.835660-1158240006397625-118364000457200-3168015Form W-9(Rev. August 2013)Department of the Treasury Internal Revenue ServiceRequest for Taxpayer Identification Number and CertificationGive Form to the requester. Do not send to the IRS.Print or typeSee Specific Instructions on page 2.Name (as shown on your income tax return)Business name/disregarded entity name, if different from aboveCheck appropriate box for federal tax classification:Individual/sole proprietorC CorporationS CorporationPartnershipTrust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ?Other (see instructions) ?Exemptions (see instructions):Exempt payee code (if any)Exemption from FATCA reporting code (if any)Address (number, street, and apt. or suite no.)Requester’s name and address (optional)City, state, and ZIP codeList account number(s) here (optional)Part ITaxpayer Identification Number (TIN)Social security number––00Form W-9(Rev. August 2013)Department of the Treasury Internal Revenue ServiceRequest for Taxpayer Identification Number and CertificationGive Form to the requester. Do not send to the IRS.Print or typeSee Specific Instructions on page 2.Name (as shown on your income tax return)Business name/disregarded entity name, if different from aboveCheck appropriate box for federal tax classification:Individual/sole proprietorC CorporationS CorporationPartnershipTrust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ?Other (see instructions) ?Exemptions (see instructions):Exempt payee code (if any)Exemption from FATCA reporting code (if any)Address (number, street, and apt. or suite no.)Requester’s name and address (optional)City, state, and ZIP codeList account number(s) here (optional)Part ITaxpayer Identification Number (TIN)Social security number––454025641985Employer identification number–Part IICertification00Employer identification number–Part IICertificationEnter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.Under penalties of perjury, I certify that:The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), andI am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, andI am a U.S. citizen or other U.S. person (defined below), andThe FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.4495801206500Sign HereSignature ofU.S. person ?Date ?General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.Future developments. The IRS has created a page on for information about Form W-9, at w9. Information about any future developments affecting Form W-9 (such as legislation enacted after we release it) will be posted on that page.Purpose of FormA person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, payments made to you in settlement of payment card and third party network transactions, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),Certify that you are not subject to backup withholding, or45402537465000Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to thewithholding tax on foreign partners’ share of effectively connected income, andCertify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct.Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:An individual who is a U.S. citizen or U.S. resident alien,A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,An estate (other than a foreign estate), orA domestic trust (as defined in Regulations section 301.7701-7).Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are aU.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.45402520383500Form W-9 (Rev. 8-2013)Page 2In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity,In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust, andIn the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.The treaty article addressing the income.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.The type and amount of income that qualifies for the exemption from tax.Sufficient facts to justify the exemption from tax under the terms of the treaty article.Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years.However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.Payments you receive will be subject to backup withholding if:You do not furnish your TIN to the requester,You do not certify your TIN when required (see the Part II instructions on page 3 for details),The IRS tells the requester that you furnished an incorrect TIN,The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), orYou do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of FormW-9 for more information.Also see Special rules for partnerships on page 1.What is FATCA reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.Updating Your InformationYou must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies.PenaltiesFailure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.Specific InstructionsNameIf you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form.Sole proprietor. Enter your individual name as shown on your income tax return on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name/disregarded entity name” line.Partnership, C Corporation, or S Corporation. Enter the entity's name on the “Name” line and any business, trade, or “doing business as (DBA) name” on the “Business name/disregarded entity name” line.Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulation section 301.7701-2(c)(2)(iii). Enter the owner's name on the “Name” line. The name of the entity entered on the “Name” line should never be a disregarded entity. The name on the “Name” line must be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on the “Name” line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the “Business name/disregarded entity name” line. If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.Note. Check the appropriate box for the U.S. federal tax classification of the person whose name is entered on the “Name” line (Individual/sole proprietor, Partnership, C Corporation, S Corporation, Trust/estate).Limited Liability Company (LLC). If the person identified on the “Name” line is an LLC, check the “Limited liability company” box only and enter the appropriate code for the U.S. federal tax classification in the space provided. If you are an LLC that is treated as a partnership for U.S. federal tax purposes, enter “P” for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for C corporation or “S” for S corporation, as appropriate. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701-3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the “Name” line) is another LLC that is not disregarded for U.S. federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the “Name” line.Other entities. Enter your business name as shown on required U.S. federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name/disregarded entity name” line.ExemptionsIf you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and Exemption from FATCA reporting code on page 3.45402520383500Form W-9 (Rev. 8-2013)Page 3Exempt payee code. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.The following codes identify payees that are exempt from backup withholding: 1—An organization exempt from tax under section 501(a), any IRA, or acustodial account under section 403(b)(7) if the account satisfies the requirementsof section 401(f)(2)2—The United States or any of its agencies or instrumentalities3—A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities4—A foreign government or any of its political subdivisions, agencies, or instrumentalities5—A corporation6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States7—A futures commission merchant registered with the Commodity Futures Trading Commission8—A real estate investment trust9—An entity registered at all times during the tax year under the Investment Company Act of 194010—A common trust fund operated by a bank under section 584(a) 11—A financial institution12—A middleman known in the investment community as a nominee or custodian13—A trust exempt from tax under section 664 or described in section 4947 The following chart shows types of payments that may be exempt from backupwithholding. The chart applies to the exempt payees listed above, 1 through 13.IF the payment is for . . .THEN the payment is exempt for . . .Interest and dividend paymentsAll exempt payees except for 7Broker transactionsExempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.Barter exchange transactions and patronage dividendsExempt payees 1 through 4Payments over $600 required to be reported and direct sales over $5,0001Generally, exempt payees 1 through 52Payments made in settlement of payment card or third party network transactionsExempt payees 1 through 41 See Form 1099-MISC, Miscellaneous Income, and its instructions.2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank.Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements.A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)B—The United States or any of its agencies or instrumentalitiesC—A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalitiesD—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472-1(c)(1)(i)E—A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i)F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any stateG—A real estate investment trustH—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940I—A common trust fund as defined in section 584(a) J—A bank as defined in section 581K—A brokerL—A trust exempt from tax under section 664 or described in section 4947(a)(1) M—A tax exempt trust under a section 403(b) plan or section 457(g) planPart I. Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.Note. See the chart on page 4 for further clarification of name and TIN combinations.How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at . You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting or by calling 1-800- TAX-FORM (1-800-829-3676).If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.Part II. CertificationTo establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the “Name” line must sign. Exempt payees, see Exempt payee code earlier.Signature requirements. Complete the certification as indicated in items 1 through 5 below.Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.45402520383500Form W-9 (Rev. 8-2013)Page 4447675257175For this type of account:Give name and SSN of:IndividualTwo or more individuals (joint account)Custodian account of a minor (Uniform Gift to Minors Act)a. The usual revocable savings trust (grantor is also trustee)b. So-called trust account that is not a legal or valid trust under state lawSole proprietorship or disregarded entity owned by an individualGrantor trust filing under Optional Form 1099 Filing Method 1 (see Regulation section 1.671-4(b)(2)(i)(A))The individualThe actual owner of the account or, if combined funds, the first1individual on the account2The minor1The grantor-trustee1The actual owner3The ownerThe grantor*For this type of account:Give name and EIN of:Disregarded entity not owned by an individualA valid trust, estate, or pension trustCorporation or LLC electing corporate status on Form 8832 or Form 2553Association, club, religious, charitable, educational, or other tax-exempt organizationPartnership or multi-member LLCA broker or registered nomineeAccount with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program paymentsGrantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671-4(b)(2)(i)(B))The owner4Legal entityThe corporationThe organizationThe partnershipThe broker or nominee The public entityThe trust00For this type of account:Give name and SSN of:IndividualTwo or more individuals (joint account)Custodian account of a minor (Uniform Gift to Minors Act)a. The usual revocable savings trust (grantor is also trustee)b. So-called trust account that is not a legal or valid trust under state lawSole proprietorship or disregarded entity owned by an individualGrantor trust filing under Optional Form 1099 Filing Method 1 (see Regulation section 1.671-4(b)(2)(i)(A))The individualThe actual owner of the account or, if combined funds, the first1individual on the account2The minor1The grantor-trustee1The actual owner3The ownerThe grantor*For this type of account:Give name and EIN of:Disregarded entity not owned by an individualA valid trust, estate, or pension trustCorporation or LLC electing corporate status on Form 8832 or Form 2553Association, club, religious, charitable, educational, or other tax-exempt organizationPartnership or multi-member LLCA broker or registered nomineeAccount with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program paymentsGrantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671-4(b)(2)(i)(B))The owner4Legal entityThe corporationThe organizationThe partnershipThe broker or nominee The public entityThe trustWhat Name and Number To Give the RequesterNote. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.Secure Your Tax Records from Identity TheftIdentity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.To reduce your risk:Protect your SSN,Ensure your employer is protecting your SSN, andBe careful when choosing a tax preparer.If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at1-877-777-4778 or TTY/TDD 1-800-829-4059.Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: spam@ or contact them at idtheft or 1-877- IDTHEFT (1-877-438-4338).Visit to learn more about identity theft and how to reduce your risk.1List first and circle the name of the person whose number you furnish. If only one person on ajoint account has an SSN, that person’s number must be furnished.2Circle the minor’s name and furnish the minor’s SSN.3You must show your individual name and you may also enter your business or “DBA” name onthe “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.4List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of thepersonal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1.*Note. Grantor also must provide a Form W-9 to trustee of trust.454025-2476500Privacy Act NoticeSection 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.FORM L: Certificate of Insurance (Acord Form) Please include the Certificate of Insurance (Acord Form) or a Letter from its insurance provider stating that proposer can provide the levels of insurance required in this RFP – section FORM m: ACKNOWLEDGEMENT FORM RFP/RFQ Number:Project Name:RFP/RFQ Due Date / Bid Opening:THIS ACKNOWLEDGEMENT FORM MUST BE SIGNED AND RETURNED WITH YOUR PROPOSAL RESPONSE TO ACKNOWLEDGE AND AFFIRM AGREEMENT TO ALL OF THE STATEMENTS AND TERMS & CONDITIONS CONTAINED IN THIS REQUEST FOR PROPOSAL/QUALIFICATION. THE AUTHORIZED SUPPLIER REPRESENTATIVE MANUALLY SIGNING THIS ACKNOWLEDGEMENT FORM WARRANTS THAT THEY ARE IN RECEIPT OF THE FULL REQUEST FOR PROPOSAL AND ARE DULY AUTHORIZED TO COMMIT ON BEHALF OF THEIR COMPANY TO CONTRACTUAL OBLIGATIONS AND PRICING.I hereby acknowledge that I have received and read the following parts of the proposal in its entirety: DocumentsInitialsPart I: General Terms and Conditions Part II: Request for Proposals - Scope of WorkPart III: AttachmentsVENDOR AGREES TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE, AND LOCAL LAWS, RULES, REGULATIONS, AND ORDINANCES. IT IS FURTHER ACKNOWLEDGED THAT VENDOR CERTIFIES COMPLIANCE WITH ALL PROVISIONS, LAWS, ACTS, REGULATIONS, ETC. AS SPECIFICALLY NOTED ABOVE. Vendor’s Name: _______________________________________________________________________________________Address, City, State, and Zip Code: ________________________________________________________________________Phone Number: ____________________________________ Fax Number: ____________________________________ Printed Name and Title of Authorized Representative: __________________________________________________________Email Address: ________________________________________________________________________________________Signature of Authorized Representative: ____________________________________ Date: ___________________________FORM n: (NOT USED)FORM o: Criminal History Background Check FORM**THIS DOCUMENT MUST BE SIGNED AND SUBMITTED WITH THE PROPOSAL **TO: The Office of Ethics and ComplianceHouston Independent School DistrictIN REFERENCE:RFP # {{Insert # and name of project here}}- Criminal History Background Check Form – No direct contact with studentsDATE: {{Insert Date}}As required by the Houston Independent School District contract, {{insert project #, and name here}}, I hereby certify that no employee and/or subcontractor of {Vendor Name} will have direct contact with any student at HISD as defined under 19 Texas Administrative Code 153.1101, which states:(7)??Direct contact with students--The contact that results from activities that provide substantial opportunity for verbal or physical interaction with students that is not supervised by a certified educator or other professional district employee. Contact with students that results from services that do not provide substantial opportunity for unsupervised interaction with a student or students, such as addressing an assembly, officiating a sports contest, or judging an extracurricular event, is not, by itself, direct contact with students. However, direct contact with students does result from any activity that provides substantial opportunity for unsupervised contact with students, which might include, without limitation, the provision of coaching, tutoring, or other services to students.PROVIDER[Insert company name & remove this print] By: _________________Date_______ (Type name & title of authorized representative, date signed and signature below & remove this print)_____________________Taxpayer Identification Number Signature of person receiving document: _______________________________________Date Received by OEC: ___________________Form: NO CONTACT DIRECT CONTACT**THIS DOCUMENT MUST BE SIGNED IF DIRECT CONTACT WITH STUDENT *******TO: The Office of Ethics and ComplianceHouston Independent School DistrictIN REFERENCE: RFP # {{Insert # and name of project here}}- Criminal History Background Check Form - With direct contact with StudentsDATE: {{Insert Date}}As required by the Houston Independent School District contract, {{insert project #, and name here}}, I hereby certify that the attached list of employees and/or subcontractors of {Vendor Name} will have direct contact with students at HISD as defined under 19 Texas Administrative Code 153.1101, which states:(7)??Direct contact with students--The contact that results from activities that provide substantial opportunity for verbal or physical interaction with students that is not supervised by a certified educator or other professional district employee. Contact with students that results from services that do not provide substantial opportunity for unsupervised interaction with a student or students, such as addressing an assembly, officiating a sports contest, or judging an extracurricular event, is not, by itself, direct contact with students. However, direct contact with students does result from any activity that provides substantial opportunity for unsupervised contact with students, which might include, without limitation, the provision of coaching, tutoring, or other services to students.PROVIDER[Insert company name & remove this print] By: _________________Date_______ (Type name & title of authorized representative, date signed and signature below & remove this print)_______________________Taxpayer Identification Number Signature of person receiving document: _______________________________________Date Received by OEC: ___________________Form: NO CONTACT DIRECT CONTACTTHIS DOCUMENT MUST BE COMPLETED IF DIRECT CONTACT WITH STUDENTLIST ALL NAMES OF EMPLOYEES AND DATES OF BIRTH OF THOSE WHO REQUIRE A BACKGROUND CHECK:(TO BE COMPLETED BY VENDOR AND SUBMITTED WITH THE REPONSE TO THE RFP AND /OR CONTRACT.)NAMEDATE OF BIRTH_____________________________________________________________ Name of Vendor/Provider & Project #_____________________________________________________________ Signature / Date ................
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